=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174205314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SETH DANIEL BLANKENSHIP PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 08/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2217 PARK BEND DR STE 240
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-5674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-866-3073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 RIVERY BLVD APT 4210
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-3039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-866-3073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 1379060
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------